A Review of Mammary Ductoscopy in Breast Cancer

Breast papillary lesions: an analysis of 70 cases

Introduction

Papillary breast lesions are rare and constitute less than 10% of benign breast lesions and less than 1% of breast carcinomas.

Objective

To analyse the clinical presentation, preoperative evaluation, and surgical and anatomopathological characteristics of the patients operated on for papillary breast lesions.

Material and Methods

Retrospective descriptive and analytical study. We analysed the database of patients with definitive histopathological diagnosis of papillary breast lesions operated on at our institution from January 2004 to May 2013.

Results

During the period described, 70 patients with histopathological diagnosis of papillary breast lesions were operated upon. The median age was 50 years (19–86 years). Thirty-seven patients (52.8%) were symptomatic at diagnosis. Preoperative ultrasound was reported to be altered in all patients. A mammography showed pathologic findings in only 50% of cases. All patients underwent partial mastectomy, after needle localisation under ultrasound, if the lesion was not palpable on physical examination. The final pathological diagnosis was: benign papillary lesion in 55 patients (78.6%) and malignant in 15 patients (21.4%). Adjuvant treatment was performed in all malignant cases. Median follow-up was 46 months (3–115 months).

Conclusions

Patients with papillary breast lesions presented with symptoms in half of all cases. There was a high frequency of malignancy (21.4%), therefore surgical resection was recommended for papillary breast lesions.

Correlation of ductal lavage cytology with ductoscopy-directed duct excision histology in women at high risk for developing breast cancer: a prospective, single-institution trial

OBJECTIVES

The study was designed to determine which histological lesions produce cellular atypia in lavage specimens and whether ductoscopy adds useful information for the evaluation of high-risk patients with atypical lavage cytology.

METHODS

We prospectively recruited women ≥35 years at high risk for developing breast cancer. All underwent ductal lavage. Women found to have atypia underwent ductoscopy-directed duct excision (group 1). Women without atypia were observed (group 2). Data included patient demographics, risk assessment, cytologic and histologic findings, and outcomes. Descriptive statistics were utilized for data summary and were compared using Fisher's exact test.

RESULTS

We enrolled 102 women; 93 (91%) were Caucasian. Their median age was 49 (range 34-73) years with a median follow-up of 80 (range 5-90) months. Overall, 27 (26%) had atypical lavage cytology (group 1), and 75 (74%) had benign cytology (group 2). Subsequent duct excision in group 1 revealed benign histology in 11 (44%), papillomas in 9 (36%), atypical hyperplasia (AH) in 4 (16%), and ductal carcinoma in situ (DCIS) in 1 (4%). At follow-up, three patients developed breast cancer, including one group 1 patient and two group 2 patients. There were no differences between groups 1 and 2 according to patient demographics, Gail scores, or risk for subsequent breast cancer (P > 0.05).

CONCLUSIONS

Although 20% of high-risk women with ductal lavage atypia have AH or malignancy on subsequent excision, the majority do not. Atypia identified by ductal lavage is not associated with a higher risk of developing subsequent breast cancer, even in this high-risk population.

In vitro delivery of anti-breast cancer agents directly via the mammary papilla (nipple)

The objective of this study was to investigate, in vitro, the plausibility of a novel method for delivering a combination of anti-breast cancer agents to the breast via the mammary papilla (nipple). Mammary papillae were prepared from freshly excised strips of porcine sow breasts by blunt dissection. Permeation studies were performed using all glass Franz diffusion cells in both upright and lateral position, with drugs examined individually and in combination. Donor phase was comprised of equimolar PD98059, LY294002 and tamoxifen; 2.54x10(-4) mol dissolved in 950 microL fish oil (containing approximately 23% (w/v) eicosapentaenoic acid, EPA), 25 microL DMSO and 25 microL 1,8-cineole. Also, 4 or 10% Cabosil M5P (w/v) was added to thicken the formulation. After 6 h, the papillae were recovered, cleaned, centrifuged and extracted thrice with methanol. Pooled extracts were analysed by reversed-phase HPLC. The significance of the papilla orientation was also investigated. When applied singly and laterally, the amount extracted from the porcine breast tissue for PD98059, LY294002 and tamoxifen were 1.83+/-0.30, 10.67+/-1.78 and 0.74+/-0.19x10(-2) micromol g(-1) respectively; applied simultaneously and laterally, 2.03+/-0.14, 4.86+/-0.47 and 0.22+/-0.04x10(-2) micromol g(-1) respectively. With 4% Cabosil formulation, amount extracted for PD98059 and LY294002 were 5.71+/-0.95 and 9.91+/-0.92x10(-2) micromol g(-1) respectively; with 10% formulation, 2.64+/-0.5 and 3.90+/-0.78x10(-2) micromol g(-1) respectively. Tamoxifen was below its limit of detection in both Cabosil M5P formulations. To conclude, localized passive delivery via the mammary papilla is a plausible non-invasive means of delivering anti-breast cancer drugs directly to the breast, in levels that have previously been shown to markedly inhibit the growth of breast cancer cell lines, in vitro. The amounts deliverable may be influenced by differential interactions with the thickening agent and patient orientation.

Minimally invasive technology in the management of breast disease

Minimally invasive surgery is gaining popularity around the world because it achieves the same or even superior results when compared to standard surgery but with less morbidity. Minimally invasive breast surgery is a broad concept encompassing new developments in the field of breast surgery that work on this minimally invasive principle. In this regard, breast-conserving surgery and sentinel lymph node biopsy are good illustrations of this concept. There are three major areas of progress in the minimally invasive management of breast disease. First, percutaneous excisional devices are now available that can replace the surgical excision of breast mass lesions. Second, various ablative treatments are capable of destroying breast cancers in situ instead of surgical excision. Third, mammary ductoscopy provides a new approach to the investigation of mammary duct pathology. Clinical experience and potential applications of these new technologies are reviewed.

The role of major duct excision and microdochectomy in the detection of breast carcinoma

BACKGROUND

The association of nipple discharge with breast carcinoma has resulted in numerous women undergoing exploratory surgery to exclude malignancy. The aim of this study was to determine whether pre-operative factors can identify those patients that are most at risk of carcinoma.

METHODS

All patients over a 14-year period (1991-2005) who had a microdochectomy or subareolar exploration for the evaluation of nipple discharge were assessed. Patient characteristics, pre-operative imaging and pathological findings were analysed.

RESULTS

Of the 211 patients included in this study, 116 patients had pathological (unilateral, uniductal serous or bloody) discharge. On excision, 6% (n = 7) of patients with pathological discharge and 2.4% (n = 2) of patients with non-pathological discharge were diagnosed with carcinoma. Overall, major duct excision resulted in the diagnosis of carcinoma in 4.3% (n = 9), ADH/LCIS in 4% (n = 8), papilloma in 39% (n = 83), and duct ectasia or non-specific benign disease in 53% (n = 111) of patients. In the patients determined to have malignancy, 44% (n = 4) were premenopausal. No patient with a non-bloody discharge in the total population analysed (28%; n = 59/211), or in the population with a pathological discharge (21%; n = 24/116) was found to have carcinoma upon excision.

CONCLUSION

Microdochectomy or major duct excision performed for nipple discharge resulted in a low rate of malignancy on excision. Conservative management of non-bloody nipple discharge can be considered in patients with no other clinical or radiological signs of malignancy.

Morphologic and immunophenotypic markers as surrogate endpoints of tamoxifen effect for prevention of breast cancer

Prevention trials using incidence or mortality as endpoints require a large number of participants and long follow-up. Trials using biomarkers as endpoints would potentially require fewer participants, less time, and significantly less resources to test promising new agents for breast cancer prevention. To test this idea, a randomized trial of tamoxifen for 1 year versus observation for 1 year was conducted to determine whether tamoxifen can cause regression of hyperplastic breast tissue, whether it changes the biomarker phenotype of premalignant disease or normal breast epithelium, and if biomarkers can be used as early surrogate indicators of response to tamoxifen. Women were identified by having an abnormal mammogram and ductal hyperplasia diagnosed by core needle biopsy. Image-directed needle biopsy was repeated in the same site of the breast after 1 year. Approximately 3000 women were screened, and 265 were eligible. Sixty-three women were randomized and paired biopsies from 45 subjects were available for analysis. There was no evidence of substantial regression of hyperplasia--fewer samples showed hyperplasia at 1 year follow-up, but this was seen in both untreated and tamoxifen-treated women. There were trends for reductions in ER and PgR and trends for increases in bcl-2 in normal and hyperplastic tissue in the tamoxifen-treated arm, though these changes did not reach statistical significance. Proliferation, determined by Ki67 staining, was not significantly changed. Clinical trials of this type are difficult to carry out and modifications in trial design are needed to make this process more efficient.

Lymphoscintigraphy and triangulated body marking for morbidity reduction during sentinel node biopsy in breast cancer

Current trends in patient care include the desire for minimizing invasiveness of procedures and interventions. This aim is reflected in the increasing utilization of sentinel lymph node biopsy, which results in a lower level of morbidity in breast cancer staging, in comparison to extensive conventional axillary dissection. Optimized lymphoscintigraphy with triangulated body marking is a clinical option that can further reduce morbidity, more than when a hand held gamma probe alone is utilized. Unfortunately it is often either overlooked or not fully understood, and thus not utilized. This results in the unnecessary loss of an opportunity to further reduce morbidity.

Optimized lymphoscintigraphy and triangulated body marking provides a detailed 3 dimensional map of the number and location of the sentinel nodes, available before the first incision is made. The number, location, relevance based on time/sequence of appearance of the nodes, all can influence 1) where the incision is made, 2) how extensive the dissection is, and 3) how many nodes are removed. In addition, complex patterns can arise from injections. These include prominent lymphatic channels, pseudo-sentinel nodes, echelon and reverse echelon nodes and even contamination, which are much more difficult to access with the probe only. With the detailed information provided by optimized lymphoscintigraphy and triangulated body marking, the surgeon can approach the axilla in a more enlightened fashion, in contrast to when the less informed probe only method is used. This allows for better planning, resulting in the best cosmetic effect and less trauma to the tissues, further reducing morbidity while maintaining adequate sampling of the sentinel node(s).

Current directions for COX-2 inhibition in breast cancer

Chemotherapy is effective against breast cancer. COX-2 has been implicated in the progression and angiogenesis of cancers. Celecoxib, a cyclooxygenase type 2 (COX-2) inhibitor, has both apoptotic and antiangiogenic activities, and may be of use in treatment of breast tumors which overexpress the COX-2 enzyme. Preliminary clinical trials have shown that the combination of chemotherapy with celecoxib has minimal additional toxicity and it may enhance the effects of the chemotherapy. Beside chemotherapy, celecoxib may promulgate the effect of aromatase inhibitor in breast cancer cells. Animal studies have shown that there are fewer and smaller tumors treated by combining exemestane and celecoxib. Larger clinical trials should be initiated to study the potential anti-cancer effects of celecoxib in breast cancer.

Breast ductoscopy with a 0.55-mm mini-endoscope for direct visualization of intraductal lesions

Standard radiologic examinations of breast duct lesions can give only indirect information. Mini-endoscopy with a breast ductoscope of only 0.55 mm offers direct visualization of the lesion and helps in the decision to perform or avoid exploratory breast tissue resection. We used a LaDuScope (PolyDiagnost, Pfaffenhofen, Germany) with a 0.55- or 0.95-mm outer diameter and a 75-mm working length from October 2003 through July 2004 on 11 women (average age of 48.3 years [range 36-69 years]) with suspicious nipple discharge. The optics have zero-degree direct view, 70-degree field vision, and 3000 or 6000 pixel resolution. Breast ducts and walls could be easily inspected; and irrigation of breast ducts, aspiration, and use of cytology brush were possible under visual control. We had no intraoperative or postoperative complications. The new procedure of mini-ductoscopy is feasible, safe, and helpful as an additional ambulatory diagnostic method for visual inspection of breast ducts. This instrument demonstrates the latest advances of technology and a trend toward less-invasive diagnostics for breast duct lesions.

Effect of perductal paclitaxel exposure on the development of MNU-induced mammary carcinoma in female S-D rats

BACKGROUND

Breast carcinoma and precancer are thought to start in the lining of the milk duct or lobule.

METHODS

At 5weeks of age, rats received a intraperitoneal (ip) injection of MNU for carcinogenesis. After mammary tumors were identified macroscopically using fiberscope, the rats were treated with perductal (pd) or ip injection of paclitaxel tri-weekly. At 36 weeks after MNU injection, tumor burden (No. of >1cm palpable mammary tumors/rat), total number of mammary carcinoma, apoptosis (AI), and microvessel density (MVD) were measured.

RESULTS

The administration of paclitaxel through the duct did not produce any toxic side effect. The tumor burden and total number of mammary carcinoma in the pd paclitaxel-treated group were significantly reduced compared to those seen in the ip paclitaxel-treated group. In addition, in the pd paclitaxel-treated group, AI was also increased and MVD was decreased, compared to those in the ip paclitaxel-treated group.

CONCLUSION

Local administration of paclitaxel may be useful for treatment of breast cancer.